What does access to care look like in a patient-centered medical home?
To answer this we first have to see what access looks like now, under our current system.
What happens now?
A patient wakes up in the morning with abdominal pain, cannot reach us, and so turns to the computer and types “abdominal pain” into Google. He or she is rewarded with multiple catastrophic and deadly diagnoses, most of which they assume they have. As frustration over not being able to reach us or be seen builds throughout the day the patient is more and more convinced they need a CT scan or MRI to rule out this impending terminal outcome.
This is not an unusual scenario. Have you ever tried to reach your doctor before office hours or, even worse, during office hours? At night a reliable answering service is available; during the day can be another matter altogether. Most frustrating of all may be during the day when the answering service picks up because the staff has signed out to them early or for a long lunch. You know they’re there, but you just can’t reach them.
I can’t even get my own office on the phone, and I know who’s sitting at which desk, and I know all the secret backdoor numbers to try.
Phones ring endlessly, go to endless queues, computerized telephone trees that take you nowhere, and after someone finally answers, you can be placed on hold to listen to an entire opera before a live person returns.
Even if phones are picked up promptly by a real person, there’s no guarantee the patient can get the physician’s attention.
In the morning when I arrive at work I don’t have time to check my email or voice mail, because my first four patients are already here and waiting.
The in-basket of my EHR is full of various different types of messages I need to check (patient advice, refill request, appointment request, non-urgent message for the ractice). Often patients routinely ignore the admonition not to leave a message here saying they are having abdominal pain and need to speak with someone urgently.
Models of advanced access, including patient-controlled scheduling, have been tried with variable success. There’s something to be said for having a patient able to put themselves directly on a provider’s schedule, but it may not truly be the best way to get this done.
How can it work at its best?
If I or a member of my team can be reached, we may be able to talk them through it, listen to their symptoms and concerns, elicit a more detailed history, and possibly give them something to try (some Pepto-Bismol or TUMS) and then check back with them later. Or even offer an urgent same-day appointment in the practice.
I can’t be there 24 hours a day, 7 days a week; none of us can. We need to build a system that gives patients access to safe and effective healthcare, while preventing the unnecessary emergency room visits they turn to when they’re fed up with being unable to reach us or be seen.
We need to make specialists and subspecialists more accessible as well. And imaging and procedures. No one’s appointments should be considered too precious to be available in a more timely fashion when it benefits patients and creates better care.
My patients are constantly told that someone can’t see them or they cannot get a test done for 2 or 3 months, when undoubtedly there’s really more availability for more urgent care than this.
Maybe in the future even the subspecialists will have their schedules wide open for access by a practitioner who has assessed the patient and found them wanting of that doctor’s care.
In our academic faculty practice, there are additional challenges facing access due to the fact that we are not always there and available. There are days when we have administrative responsibilities, sessions or even whole days where we are not seeing patients because we are supervising residents in their practice.
Similarly, the residents are not always available because of the extra time spent in education sessions while on ambulatory block, or the time away from their practice on inpatient rotations.
But by taking advantage of advanced access, improved ways to reach providers, use of more midlevel providers for triage and interim care, and expanded team coverage, we can only continue to improve on the current poor system of access that no doubt gives our patients more abdominal pain that what they woke up with this morning.
Fred N. Pelzman is an associate professor of medicine, New York Presbyterian Hospital and associate director, Weill Cornell Internal Medicine Associates, New York City, NY. He blogs at Building the Patient-Centered Medical Home.
